Introduction: A high incidence of pin loosening, infection and discomfort as well as pressure ulceration from the jacket were noted in a study performed in 1986¹ we aimed to compare our figures with published literature.

Methods: A retrospective case note review (1994–2004). One investigator reviewed the casenotes and corroborated these with a spinal database, theatre database and microbiology results system.

Results: 74 halos were applied in the 10-year period. A complete dataset was obtained for 37 patients (others had been destroyed either entirely or relevant volumes). Age range was 22–83 years (median 49), 20 males and 17 females.

28 were applied under local anaesthetic (LA), one with LA and sedation and 8 were applied under general anaesthetic (either for another trauma procedure or due to head injury). All halos applied were Bremer Halo Crown with Classic or Classic II vest (DePuy Spine, Warsaw, IN, USA).

Indications for application included fractures (n=21), tumours (n=6) or subluxations (n=10).

8 patients required pin repositioning. This was due to poor position (n=2), pain (n=5) and pin loosening (n=1, 3%). Pin site infection was diagnosed using an accepted definition2. This occurred in 5 patients. 3 settled with antibiotics, one with debridement and one with repositioning. Overall infection rate was 13.5%, which compares favourably with published rates of 20–22%. Pin site infection dropped significantly after introduction of a pin care regimen introduced and published by our limb reconstruction team² from three patients to one patient. Pin torque was also checked daily for seven days followed by weekly thereafter.

The halo vest was a cause of significant morbidity in terms of pressure ulceration (3 patients) pneumonia (3 ventilated ITU patients of whom 2 died) and pain in one patient.

Conclusion: Our pin loosening rate was significantly lower than published figures, which we ascribe to regular torque checking and use of a 0.90 Nm torque wrench³.

Our pin site infection rate dropped significantly after use of our limb reconstruction teams pin care regimen. We now utilise this regimen in all halo patients with good effect. A prospective study is ongoing.

Objective: This was to analyse RLBUHT orthopaedic spinal service’s provision of spinal care and to determine the impact on the need for surgery.

Methods: This was a three-year retrospective cohort study of orthopaedic patients with spinal related problems from January 2003 to January 2006. The sample included all patients referred to the service by general practitioners in Liverpool. Patients were examined by orthopaedic musculoskeletal physiotherapists lead by senior specialist therapists. The latter had autonomy to access imaging investigations and blood tests. Patients were referred to the consultant surgeons for surgical consideration when appropriate or to the physiotherapy department for non-surgical management. Outcome measures used included the Stockport Scale, the Roland and Morris Disability Questionnaire, the Neck Disability Index, the Euroquol Questionnaire and the Visual Analogue Scale.

Results: 17,214 patients were referred to the service from January 2003 to January 2006. 9,896 patients attended, 2,600 failed to attend and 4,718 cancelled their appointments. The number of referrals increased from 4,499 in 2003 to 5,695 in 2004, and 7,020 in 2005. Patients going on for surgery remained 200 to 220 cases per annum. The waiting times to surgery decreased from 3 to 6 months, to within 3 months. An audit of 300 patients discharged from the physiotherapy department using the Stockport Scale from January 2005 to January 2006 revealed that problems were solved / goals achieved in 40.3% of patients, with significant improvement in 42.7%, some improvement in 8.3% and no improvement or no data in 8.7%.

Conclusion: Over the three-year period there has been a significant increase in the number of patients managed by this service. This has not resulted in an increase in patient waiting-time. Surgical intervention per head of population has not altered and has been sooner. Our experience demonstrates an effective model of care for large urban populations.

Background: To assess the accuracy of pedicle instrumentation placement using an image guidance system ( Medi Vision) in a pig cadaveric model.

Methods: A 4mm diameter (10cm long) screw was inserted transversely into the spinous process of a pig cadaver percutaneously using fluoroscopic guidance. The dynamic reference base (DRB) of the image guidance system was then attached to the screw. Using the navigation system both pedicles at each level were identified and 3.2mm guide wires inserted percutaneously. This process was performed for each level from D7 to L4. Actual wire placement was recorded using standard anteroposterior and lateral fluoroscopic images. Virtual trajectories generated by the image guidance system were recorded on the guidance system database. Accuracy of wire placement was then evaluated in an automated way by linear correlation between corresponding images.

Results: 20 pedicles were instrumented at 10 levels from D7 to L4. Mean estimate of accuracy for dorsal levels AP and lateral (mm). Mean = 1.452mm, standard deviation 1.57mm. Mean for lumber levels= 1.047mm, standard deviation 1.187mm

Conclusion: Lumbar pedicle instrumentation showed more accuracy when compared to dorsal pedicle instrumentation. The error of navigation that was accommodated by the image guidance system was 2mm.

There was correlation between fluoroscopic copies and virtual trajectories.

This image guidance system may not only aid in the placement of pedicle instrumentation but also assist the senior surgeon in trainee supervision.

Study Design: Prospective case series of patients with tumour involvement of the spinal column consecutively admitted to a spinal unit for consideration of surgical treatment.

Objectives: To assess the impact of surgery on the quality of the life of patients suffering from metastatic or primary tumours of spine. Pre-operative assessment included the SF-36 and Oswestry Disability Index (ODI). Other scores (eg Tokuhashi) were prospectively calculated but were not used to determine suitability for surgery.

Subjects: A total of 38 patients were assessed. Of these 25 were considered suitable for surgery. Of these 25 patients, 3 died within 3 months and one had incomplete follow-up. The remaining 21 patients underwent further assessment at 3 and 6 months. A total of 8 patients are now dead in this group. Of 13 non-operated patients, one was unable to do an initial self-assessment. Of the other 12 patients, 4 were dead before second assessment. The remaining 8 patients provided us with another self-assessment. A total of 5 patients are now dead in this group.

Outcome measures: The SF-36 and ODI were repeated at 3 and 6 months. Those patients who were not considered suitable for surgery were also reassessed at 3 and 6 months, although the groups were not strictly comparable.

Results: At the time of presentation, most of the patients were severely or completely disabled. As expected, their Physical and Mental Health Component Scores of SF-36 were lower than reference values for patients with chronic ill health. The mean Bodily Pain scores were 12.84 in the operated group and 31.19 in the group managed conservatively. The initial ODI were 57 in the operated group and 59 in the conservative group. Of 25 patients who underwent surgery, 15 had posterior stabilisation and 7 had anterior reconstruction. 1 patient had a combined approach. 1 patient was stabilized with a halo vest and another had his procedures abandoned. Pre-operative and postoperative scores were compared using a paired two tail students t test. Mean Oswestry scores showed significant improvement at the 3rd month (from 57 to 48, p=0.02) and this was maintained at the 6th month. Among the various components of the SF-36 score, the most significant improvement was seen in Bodily Pain (from 12.8 to 46.8, p=0.00006). This was also maintained at 6 months. The mean Mental component scores improved significantly at the 3rd month (from 39.5 to 48, p=0.0009) and remained improved at the 6th month (44). In the non-operated group, the situation deteriorated in all respects. Mean Bodily pain scores (from 31.16 to 14.63, p=0.001), Physical component scores (from 28.48 to 19.72, p= 0.007) & Mental component scores (from 46.41 to 38.83, p= 0.05) were all significantly worse than at the initial assessment. The mean Oswestry disability score, also showed increasing disability (from 57 to 73.5) but did not reach statistical significance (p=0.16).

Conclusions: Surgery in these patients leads to a less painful and less disabled life. The quality of life improved in terms of mental health and physical health.